Here is a real world example of the problems that exist within the healthcare industry.
This actually happened to a member of my family. I am leaving out the specific insurance company and provider information. I’m pretty sure the problem exists across the board.
Here are the facts:
My wife has osteoporosis. Her doctor recommended she get Prolia shots twice a year since they are reported to actually improve the bone mass. The pills only maintain what you have.
The shots are pretty expensive. The product comes in a pre-filled syringe that costs around $1000.00 each.
But this is absolutely necessary so the cost is secondary.
Her doctor scheduled her for the shot at a local clinic. I brought her to the appointment.
They called her in and I accompanied her. She sat down, rolled up her sleeve, and they gave her the shot. It took no more time than a flu shot. Same basic procedure.
When I received the insurance claim information a few weeks later, I saw that the clinic had charged incorrectly.
The clinic had charged the insurance company $11,000.00. Yes, you read it correctly: $11,000.00.
They itemized it as:
Syringe cost : $1000.00
Cost to administer: $10,000.00
The classified the procedure as a chemotherapy infusion. Which it was not.
I called the clinic and advised them that they billed it incorrectly. They said they would review it.
I called the insurance company and advised them of the error. They transferred me three times. Each time I explained the problem. Eventually, I had to escalate the call to a supervisor.
The insurance company supervisor came on the line. The conversation went as follows:
Me: I want to report a problem with a billing.
Supv: What is the problem?
Me: They charged you for a chemotherapy infusion and it was just a plain injection similar to a flu shot.
Supv: Did you speak with clinic?
Me: Yes, they said they would review it but I want you to get involved to make sure it gets corrected.
Supv: Are you accusing them of fraud?
Me: No, I am just alerting you that the billing was incorrect. Please call the clinic to correct it.
Supv: I can’t do that.
Me: But you have been over charged for the procedure.
Supv: Are you formally accusing the clinic of fraud?
Me: No, it may have been a mistake. I just want you to speak with them about it to get it corrected.
Supv: Well, we normally don’t get involved in this type of issue.
Me: But it’s your money.
Supv: Don’t worry about it sir, you have already hit your deductible. You won’t be charged for it.
Me: You are missing the point. You are being overcharged. It’s a waste of money. I want it corrected.
Supv: Well, all I can do it call them and ask them if they billed it correctly.
Me: Please do that.
Supv: I will call them.
Me: I want you to call me and let me know what happens.
Supv: I will call you in one week.
One week later:
Supv: Sir, I called the clinic as you requested.
Me: Did it get corrected?
Supv: They told me they billed it correctly.
Me: But it was not a chemotherapy infusion. It was a shot. You were significantly overcharged.
Supv: I have done all I can do. I asked them if they billed it correctly and they said they did.
Me: You can’t do anything else?
Supv: You would have to formally accuse them of fraud.
Me: Why do I have to accuse them? They billed you. Why can’t you open an investigation?
Supv: I can’t do that. I have done all I can do. Have a nice day sir.
The insurance company paid the clinic $2800.00 of the $11,000.00.
I had already hit my deductible so I paid nothing.
My wife called her primary care physician and requested that they administer the next shot.
Six months later she received her injection at her doctor’s office.
They charged her:
$1000.00 for the syringe.
$50.00 to administer the shot.
I paid cash in advance since the insurance company now stated the shot was not covered. They stated they would pay for the pills, but not for the injection.
We now pay cash in advance every six months for the shots.
And her checkups and bone scans have been better, so the Prolia seems to be working.
It’s obvious that healthcare is broken.
And to compound the problem, it appears no one really cares enough to fix it.
The burden now is on us. We are the watchdogs. We have to do the leg work.
Insurance companies are putting the burden on us to price the procedures like we were getting a new transmission for our car. Get multiple quotes.
I saw a commercial for an insurance company recently where they stated that the cost of a procedure could vary by $20,000.00 at different providers within the same city. They were showing off their new tool that we can use to price the procedures locally before we go under the knife.
So instead of finding out why the cost of a procedure can vary by $20,000.00 within the same city, they come up with a tool that the consumer can use to price the procedure. They are missing the whole point.
So, we are now the watchdogs. We have to scrutinize every medical bill, every prescription, every charge.
We cannot even rely on the insurance company to monitor the providers.
Until this basic problem gets addressed, health care issues will not be resolved.
We have paid millions if not billions through healthcare reform, and the basic problems have not been addressed.
Until providers, insurance companies, and consumers are all on the same page, with the same objectives and priorities, we will not fix health care in this country.
The system is broken.
Who can we count on?